I'm a doctor. Must you trust me?

The Doctor, by Luke Fildes

When Luke Fildes painted The Doctor in 1891 as a tribute to the status of the English doctor, it was heralded by the doctors at the time as a symbol of their profession. The painting depicts a well-dressed doctor sitting by the bed of a young patient contemplating on the next course of action, with his gaze fixed on the patient. The patient lies in bed with a hand held out in supplication. The father of the patient stands in the shadows, with a comforting hand on the distraught mother, looking at the doctor, waiting for his assessment. If need be, the doctor will dispense some medication. If need be, he will roll up his sleeves and operate. The painting was drawn at a time when there was little doctors could do in terms of treatment. Yet the family places their trust in him fully, and the doctor is allowed to get near the child that they value and love, with the belief that the doctor will act for the benefit of the child, instead of harming him. There is uncertain knowledge about what action the doctor will take and the family depends on the doctor’s ‘expertise’ to cure their child. This vulnerability, uncertainty and dependence forms the basis of trust, and in many ways, the sense of trust that emanates from this iconic picture is characteristic of the trust public places in the medical profession. 

The doctor-patient relationship is one that is grounded on trust. There is a tacit belief in the doctor’s goodwill and competence, resulting from an imbalance of power between the patient and doctor in terms of knowledge. And where there is ignorance, and uncertainty, trust is a must. The lack of knowledge seems crucial to the notion of trust. Even where knowledge is possible, as when the patient is a doctor himself, he must feign ignorance, because trust is described as one of the virtues of being a good patient, together with truthfulness, justice, and probity. Trust is required because medical care depends upon judgement calls that are not predictable, and the good patient is one who recognizes this. A doctor is not allowed to treat himself as his judgement is deemed clouded when sick, and he must submit to the treatment of other doctors and pretend not to be certain of outcomes. The struggle here is obvious, and it is not surprising that doctors qua doctors turn out to be the worst of patients. 

A trustworthy person is someone who has a quality that we desire, and we trust our doctors to have goodwill towards us and to work in our best interests. The burden of trust mostly rests on the doctor because he has to work for our best interest, while being impartially concerned for our wellbeing. When we put trust in our doctor, we do so on the assumption that the probability of him doing what is beneficial to us is higher than what is detrimental, high enough for us to consider cooperating with him. Trust therefore enables patients to co-operate in making clinical decisions together. But while the doctor’s goodwill towards the patient would be desirable, it is not a necessary condition for trust. The patient may well know that the doctor bears him little good will and regards him as a gomer, yet trust him to treat him competently. The patient only has to trust the doctor to provide a good outcome for the patient. For his part, the patient could regard the doctor as a ‘dirtball’, be seductive or deceptive, or even pretend to be ill and the doctor would still have to treat him.

Trust also works to reduce the many complexities that arise in the modern health care setting. Medicine has become complex and highly technical, and it does little good for the patient to know every detail to guide the surgeon’s hands, or to know all the side effects of each medicament or all the complications of every procedure. The patient can rely and depend on the doctors to process this complex information. In the therapeutic setting, trust is instrumental because it encourages positive health behaviours such as seeking medical help, revealing sensitive information, consenting for, submitting to and complying with treatment and returning for follow-ups when advised. It is also therapeutic in the sense that it promotes healing (the placebo effect is a striking example). Trust fosters an effective healthcare relationship and also acts to promotes the doctor’s job satisfaction. Conversely, if this trust were lacking, patients are more likely to seek second opinions, to switch doctors, resort to self-treatment or alternative forms of treatment, conceal information that may be key to diagnosis or even decline to take up preventive measures such as vaccines or comply with treatment in general. The predilection of our patients to fly abroad, even for available treatment, could also be a symptom of the general lack of trust, be it in our doctors or in the system. 

Trust therefore functions to provide the context which enables the uptake of the benefits of medicine by the public. In doing so the public places its trust in both the doctor and the medical system or the medical profession. Trust for the physician derives from his professionalism and mannerisms, and the doctor-patient relationship reflects aspects of enduring emotional bonds that form early on in life, amplified cognitively over time. This trust is interpersonal and patients act under conditions of uncertainty, and choose to trust the doctor, with the assurance that the doctor will accept responsibility when this trust results in disappointment, or harmful outcomes. 

A lot of trust is hence evidently placed in medicine. What matters is not the amount of trust,  but whether this trust is well placed or not. The paternalistic conception of the doctor-patient relationship does not provide a context to put reasonable trust in because of the power and knowledge asymmetries between the doctor and the patient. Trust is only well-placed when the patient and the doctor are on an equal footing through more information and less dependence. There is a loss of context for the traditional forms of trust to arise because of considerable changes in the practice of medicine. Firstly, it has become more technical and less personal. Unlike in Luke Filde’s painting, the doctor’s gaze has come not to be fixed on the patient, “that concrete body, that visible whole, that positive plenitude that faces him” but towards…“the signs that differentiate one disease from another,” on lab reports, x-rays and the numerous equipment to which the patient is connected. This biomedical model of medicine deprives the patient of every moral and social dimension, and decisions taken at the bedside become technical and efficient, but unemotional. Secondly, patients are beginning to be more empowered and are more (if not always accurately) informed about the medical care, and are encouraged to be seen as partners in health care decision-making. The right of the patient to be informed on treatment and the right to refuse or accept treatment is well established, and professional paternalism is discouraged in modern medical practice. Instead of waiting in the shadows as a background figure as in Filde’s painting, the father would be very much in the spotlight, participating in making decisions with the doctor. In this context the patient takes on a position of trust-as-confidence rather than trust-as-faith because what necessitated trust as faith, goodwill towards the patient and lack of information, are no longer present. 

While it may be said that there is a loss of the context for trust to thrive in, with the change in medical practice, the general decline of trust in social and political institutions, weak medical regulation, more empowered patients, and a  public suspicious of failings on the part of doctors, it remains yet to ascertain if there is a crisis of decline of trust in the medical profession. However, as Justice Irwin states: "Public trust in doctors is essential to the whole enterprise of medicine. A destruction of that trust would be corrosive to the general attitude to the profession and therefore to the effectiveness overall of treatment". 

Treat Me Right

"In the absence of patient's rights, the health care setting can become a jungle" - Prof. George J Annas

Doctors have always worked for the welfare of their patients, and patients trust doctors to work towards their best interests at all times. The Hippocratic injunction “primum non nocere –first (or above all), do no harm” is the prevailing ethos of the practice of medicine. Doctors are there for the benefit of their patients and they must do them good to the best of their abilities and do nothing which they know will cause them harm. This forms the basis for the patient’s willingness to let doctors get near things she values and even harm them; the heart is trustingly placed in the cardiac surgeon’s hands, the decision on whether a loved one is dead or alive is left to the doctors, or a pill with dangerous side-effects is swallowed without a second thought. In these instances, the doctor is seen as a friend who takes care of you, with good will, fairness and integrity. And because doctors belong to a profession that is regulated and will therefore play by the rules, patients are willing to bare themselves naked, both physically and emotionally.

Based on this trust, and the underlying assumption that the “doctor knows best”, patients for the most part, are willing to submit to the vagaries of uncomfortable and painful procedures and harmful medications. And up until a few decades ago, medicine was unquestionably paternalistic with the doctor acting and deciding for the patient’s benefit, but without the specific consent of the patient being treated. Patients are seen as ‘cases’ that was done something to, rather than something with. Few patients questioned the authority of the doctor, while automatically presuming that doctors will work for their benefit. To trust was to have blind faith in the competence and the good will of the doctor. Furthermore, with the patient being not in a position of having medical knowledge, there was little alternative for the patients but to trust the doctor. Trust is required where there is ignorance.

The potential for medicine to benefit patients is, however, no greater than the potential to harm patients, sometimes with disastrous consequences such as death or lifelong disability. In the face of the possibility for such outcomes, “Trust me, I am a doctor” is no longer justifiable. And with the easy access to medical information, medical knowledge is no more the sole preserve of the medical profession, and informed patients are in a position to reduce that knowledge gap. The ignorance that necessitated trust (faith) in the doctors is lesser. This is not to say that patients need not trust their doctors any more, but that this trust should be based more on confidence than on faith. The ultimate aim of medicine is to do what is good for the patient, and patients need to be able to trust their doctors to do what is good for them, not out of good will, but because it is what is expected of them. Such trust is justified only when patients are empowered through the awareness and protection of their rights.

One fundamental right is the right for patient autonomy­ – patients must be respected as independent moral agents with the right to make decisions on all aspects of their care, based on the information that is provided to them. Doctors are now encouraged to view the decision-making process as a partnership, while embracing a more equal sharing of the medical knowledge. The patient has the right to be informed of the nature of his/her condition, the treatment options, and any complications that may arise as a result of treatment procedures. Based on this information, it is the patient who has to decide and grant the doctor the authority to treat him or her. This is the basis for the process of obtaining consent. The Constitution ensures that each person has the right to life and security of the person and touching a patient without consent is unlawful and violates his or her bodily integrity and amounts to battery, and can also result in a negligent action. The right to patient autonomy is strong enough to entitle patients to refuse treatment, even if the refusal may result in his or her death.

One other fundamental right is that of privacy and confidentiality. This is one set of rights that are ensured even in our Constitution. Article 24 states that “everyone has the right to respect for his private and family life, his home and his private communications”.  Patients have the right to expect that private information about them disclosed to the doctor will be held in confidence.  Confidentiality is central to the trust between doctors and patients because where this right is not protected, patients will be reluctant to seek care in certain circumstances or fail to disclose key information that may have direct impact on their care.

The right to a good standard of healthcare is another right that is derived from our Constitution. It states that “a good standard of health care, physical and mental” is necessary for the realization of all other rights pursuant to the Constitution. The Constitution further states that citizens must seek to achieve a “good standard of health care”. Seeking this right therefore becomes an constitutional obligation on the patient’s part and the state must ensure that citizens have access to quality healthcare. In addition to these rights that can be directly derived from our Constitution, patients have the right to be treated with dignity and respect, the right to complain about the care provided, and the right to redress when harm arises during their care.

One question that always follows from any discussion on patient rights is on the rights of health care providers. The question may seem relevant; but what list of rights can be produced? How would such a list look like?  Doctors can and will continue to enjoy the unique power that is afforded to them through their knowledge and skill in medicine. And doctors will continue to demand exceptional amounts of respect, authority, power and income. There will always remain a natural inequality in the doctor patient relationship. It is precisely because of this inequality that the rights language needs to be used, even though patients cannot be now expected to accept with resignation whatever doctors say or do to them. But society still trusts them and has granted them professional autonomy by allowing self-regulation. It is up to the medical profession to determine the standards of the profession, to ensure competency of their doctors and to discipline doctors when these standards are not met.

Thus, a contract is made between the public and the medical profession for mutual benefit, where the patient is provided a satisfactory treatment in exchange for very concrete and material professional gain from the privileges granted by the society. Doctors and providers therefore have duties and responsibilities rather than specific rights. And if they are to maintain the trust that allows them these special privileges, they have to act in a trustworthy manner. When Hippocrates formulated his infamous oath, the traditional healers could refer to it to know how to act in a way their patients would trust them. It was this that transformed the traditional healers into professionals. Hippocrates recognized the potential for doctors to harm and exploit their patients when he penned the oath that has governed the relationship between the doctor and the patient for millennia. It was acknowledged that doctors were in a position to exploit their patients and prescribes the doctor to restrain himself; prescribe only for the benefit instead of harm; not to disclose the patient’s private details obtained during the consultations; act within one’s competencies; enter homes only for the good of the patients, and to keep away from all intentional ill-doing and all seduction, especially from the pleasures of love with women or with men.  The clinical encounter was one that tempted the doctor to “manipulate, control, or otherwise take advantage of the ineluctably vulnerable person.” 

It is thus, the duty and responsibility of healthcare providers and the state to ensure that the rights of patients are protected and respected. Patients come to their doctor in a state of anxiety and vulnerability, with the outcome dependent on the nature of care provided. This vulnerability and the potential for harm and abuse it permits require that the patient be kept at the center of care. Treating a patients right becomes treatment that protects the patient’s rights.